Wednesday, September 05, 2007

Depression Ups the Risk for Heart Attack

Over the years, I've seen a number of studies that support a link between depression and heart disease, depression and stroke, depression and diabetes. Anecdotally, I've witnessed this.

The ability of depression to predict heart disease and heart attack was found to be independent of risk factors you might think would be more predictive. Barefoot et al. controlled for age, sex, systolic blood pressure, total cholesterol, triglycerides, insulin, smoking, pulmonary function, sedentary work, and sedentary leisure and still found that depression independently increased the risk for heart attack and death.1

So, you may have your cholesterol, blood pressure, and blood sugar under control. You may get enough exercise and not smoke. But if you can identify with items in the lists below, controlling for the factors I just mentioned may not be enough to stave off heart failure.

Medscape has a nice synopsis (registration is free):
Depression and Stress Hit Hard on Heart

In my experience, people are eager to tell you the intricacies of their blood work. Every last mg/dl. But they're less inclined to tell you that they haven't slept through the night in years, or that they'd rather stay in bed than do anything else. They won't tell you they barely overcome a sense of anxiousness or despair to leave the house. They'll say they've just been feeling tired lately, when what might better describe their reluctance to do things is a loss of interest ... in people, in what they used to enjoy, in life.

The National Institute of Mental Health lists the following as symptoms of depression and mania:

Depression

Persistent sad, anxious, or "empty" mood

Feelings of hopelessness, pessimism

Feelings of guilt, worthlessness, helplessness

Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex

Decreased energy, fatigue, being "slowed down"

Difficulty concentrating, remembering, making decisions

Insomnia, early-morning awakening, or oversleeping

Appetite and/or weight loss or overeating and weight gain

Thoughts of death or suicide; suicide attempts

Restlessness, irritability

Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

Mania

Abnormal or excessive elation

Unusual irritability

Decreased need for sleep

Grandiose notions

Increased talking

Racing thoughts

Increased sexual desire

Markedly increased energy

Poor judgment

Inappropriate social behavior

Although depression typically conjures a low mood, or in the case of bipolar depression, a low-high mood swing, aggression and anger are emerging as diagnosable traits for depression.2

The Medscape article from above says about anger:

"A long-term study of more than 1000 men found that those who had angry or irritable responses to stressful situations were 3 times more likely to be diagnosed with heart disease and 5 times more likely to suffer a heart attack before the age of 55. ... These results were independent of cholesterol levels, body mass index, or blood pressure. Anger was also found to increase the risk of depression and anxiety."

I'll see people shrug off, or attempt to shrug off, feelings listed above. That shrug is equivalent to ignoring the effects of clogged arteries, elevated blood pressure, sugar-loaded blood vessels, even a previous heart attack. Depression is an underrecognized, undertreated, and potent risk factor for cardiac failure.

If the goal is to fend off heart attack, why aren't physicians as eager to prescribe antidepressants and talk therapy as they are statins and ACE inhibitors? Why aren't insurance companies as eager to cover treatment for depression?

Roland von Kanel, MD, a professor of medicine and head of the psychosomatic division at University Hospital Berne in Switzerland, in response to a depression/heart attack study that appeared in the Journal of the American Collage of Cardiology in December, 20063, said:

"Given what we now know, I believe that screening for depression should be part of today's clinical practice in a cardiology setting any time a patient is referred to the ICU with a heart attack. ... Depressed patients should be treated with counseling, referral to a psychotherapist and/or antidepressant medication - preferably an SSRI (selective serotonin reuptake inhibitor) - depending upon the severity of their depression."
- Heart Attack-Related Depression Puts Patients At Risk For Further Cardiovascular Emergencies

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Depression And Diabetes

Depression is rampant in the diabetic community. One recent study placed the prevalence at about 25%.4 As a comparison, the NIH reports that about 9% of the general adult population suffers mood disorders. A study from June found that having diabetes almost doubles the risk for depression, and that there may be a link to high HbA1c (higher-than-normal blood glucose levels).5

As alluded above, those with heart disease also experience depression at a higher rate. One meta-analysis (a study of studies) found that depression can at least double or triple the risk of having a second heart attack, or of dying.6

A number of hypotheses have been put forth to explain the associations between depression and diabetes or heart disease, some organic (internal chemistry), some functional (situational, e.g. "Who wouldn't be depressed if they had to prick their finger 3 times a day and watch everything they ate?"). No one argues that the combination of depression and diabetes, or depression and heart disease, exacerbate one another. And as the meta-analysis cited above reveals, when depression and diabetes or heart disease coexist, death can come sooner.

Abstracts presented at The American Psychosomatic Society's annual meeting this year bear this out. The Washington Post summarized one of them here:
Heart Disease, Diabetes, Depression a Deadly Mix

So if the leading cause of death among people with diabetes is heart attack, and if depression hastens heart attack, and if depression is widespread among diabetics, wouldn't it make sense to have mental health screening part of the care package for these chronic diseases? I think it would.7

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1Symptoms Of Depression, Acute Myocardial Infarction, And Total Mortality In A Community Sample
2Anger Attacks In Bipolar Depression: Predictors And Response To Citalopram Added To Mood Stabilizers
3Only Incident Depressive Episodes After Myocardial Infarction Are Associated With New Cardiovascular Events
4Depression Treatment And Satisfaction In A Multicultural Sample Of Type 1 And Type 2 Diabetic Patients
5Diabetes Mellitus, Glycemic Control, And Incident Depressive Symptoms Among 70- To 79-Year-Old Persons
6Prognostic Association Of Depression Following Myocardial Infarction With Mortality And Cardiovascular Events: A Meta-Analysis
7 If an herb like St. John's wort can be shown to be as effective as pharmaceutical antidepressants ... at a lower cost and with fewer side effects ... why shouldn't we standardize and prescribe it?